[SALON & SPA] New Client Intake & Health History

It is important to answer the questions as best as possible to ensure that you receive adapted treatments, taking into consideration your personal and individual health. Thank you. [ENTER BUSINESS NAME, ADDRESS] Phone: (123) 456-6789 Email: YourName@YourEmail.com Website: YourWebsite.com

Welcome to our Spa!
Client name * First Last
Sex *
Male Female
Date of birth (DD/MM/YY) *
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Age *
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Home phone * - ### - ### ####
Cell phone - ### - ### ####
Business phone - ### - ### ####
Occupation
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Address *
Address Type Street Address Address Line 2 Apartment City State / Province / Region Postal / Zip Code Country
Email Address
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Confirm Email *
How did you hear about us? *
Newspaper Internet Yellow Pages Print flyer Building sign / Walked by Other Referral (please enter name below)
If you have had spa services before, please specify:
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Do you enjoy scents with your service? *
Yes No I'm allergic (please list allergies)
YOUR HEALTH HISTORY

This health history below will be reviewed by your esthetician (if necessary).

We may periodically ask you to complete a new health history form to monitor any new changes to your overall health which may affect the nature of the treatments you are receiving.

Please be sure to inform us of any changes prior to each visit.

Please answer each question as accurately as possible

Please choose the best answer for each question below: *
	Yes	No
Do you wear contact lenses or glasses
Are you allergic to latex
Asthma, hayfever, seasonal allergies
Cold hands and or feet
Varicose veins
Low blood pressure
High blood pressure
High anxiety and nervousness
Excessive sweating
Prone to sore throats
Prone to earaches
Diabetes
Osteoarthritis
Osteoporosis
Recent treatment with a plastic surgeon
Recent treatment with a dermatologist

Do you have allergies? *
No Yes (please specify below)
Do you often get dizzy? *
No Yes (please specify below)
Are you allergic to gluten or wheat (Celiac Disease)? *
No Yes (please specify below)
Metal in the body? *
No Yes (please specify below)
Swollen or inflamed joints? *
No Yes (please specify below)
Numbness or pain? *
No Yes (please specify below)
Heart, cardiovascular, or circulation issues? *
No Yes (please specify below)
Swelling or edema? *
No Yes (please specify below)
Dental issues or apparatus? *
No Yes (please specify below)
Stomach disorders? *
No Yes (please specify below)
Known skin conditions or concerns? *
No Yes (please specify below)

Have you, or are you currently taking the following medications: *
	Yes	No
Accutane
Glycolic Acid
High Blood Pressure
Thyroid Medication
Alpha Hydroxy Acid product
Cortisone
Retin-A (in the last six months)
Tetracycline
vitamin A derivatives

If you said "yes" to any of the above, please specify
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Do you exercise? *
5-6 days per week 3-4 days per week 1-2 days per week Not too often I do not exercise
YOUR SKIN

Please answer the following
When you cleanse (e.g. your face), what is the temperature of the water? *
Cold Lukewarm Warm Hot
Do you have any special skin problems pertaining to your face? *
No Yes, I have these issues
What skin care products are you currently using? *
Cleanser Soap Exfoliator Scrub Toner Mask Other products =
Have you ever had any of these treatments?
Microdermabrasion Chemical peels Laser treatments Resurfacing
Do you ever experience oily shine during the day? *
Yes No Occasionally
Do you ever experience skin breakouts? *
Yes No Occasionally
How much water do you drink a day?
1 cup 2 cups 3 cups 1 litre 2 litres 3+ litres
Do you experience any of the following skin conditions? *
Tightness Dryness Flakiness Other =
Do you use sunblock or sunscreen on your skin? *
No Occasionally Yes, I use SPF

Please answer the following: *
	Yes	No
Do you tan indoors (tanning bed)
Do you tan outdoors
Have you had a bad sunburn before
Do you smoke
Are you a vegetarian
Are you a vegan
Do you follow a special diet

Capillary activity: *
	Yes	No
In moderate sunlight, do you easily burn?
When nervous, do you blush easily?
Do you have a tendency to redness?
Are up prone to sinus problems?

Do you drink caffeinated beverages (soft drinks, tea, or coffee)? *
No Yes, I drink this many daily
Do you ever experience a burning, or itching sensation on your skin? *
No Yes. (please explain)
What is your pain threshold? *
Light Moderate I can handle a lot
Are you claustrophobic? *
Yes No
What type of massage pressure do you prefer? *
Light and soft A bit of pressure Firm pressure
Have you ever experienced a reaction to any of the following?
Cosmetic Medicine Iodine Pollen Food Hydroxyl acid Animals Fragrances Sunscreen

FEMALE clients only
	Yes	No
Are you pregnant or trying to become pregnant?
Are you lactating?
Are you taking oral contraception?
Are you premenopausal?
Are you menopausal?
Are you postmenopausal?

MALE clients only
	Yes	No
Do you ever experience skin irritation from shaving?
Are you prone to ingrown hairs?
Do you use an electrical shaver
Do you wet shave? (razor blade)

CLIENT SIGNATURE: I, the undersigned, realize that the purpose in providing accurate information in the above is to ensure that the salon and/or spa treatments will be appropriate for my personal health. As a result, I confirm this information to be correct. *

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Signed on this date * / MM / DD YYYY
DEAR CLIENT, PLEASE SCROLL DOWN TO THE BOTTOM AND SUBMIT YOUR FORM

(the info below is for OFFICE USE ONLY. Do not enter any info please)

Esthetician or Practioner notes for appointments
1st appointment date / MM / DD YYYY
Esthetician's name and comments regarding appointment
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2nd appointment date / MM / DD YYYY
Esthetician's name and comments regarding appointment
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Client's initials
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3rd appointment date / MM / DD YYYY
Esthetician's name and comments regarding appointment
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Client's initials
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4th appointment date / MM / DD YYYY
Esthetician's name and comments regarding appointment
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Client's initials
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5th appointment date / MM / DD YYYY
Esthetician's name and comments regarding appointment
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Client's initials
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6th appointment date / MM / DD YYYY
Esthetician's name and comments regarding appointment
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Client's initials
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7th appointment date / MM / DD YYYY
Esthetician's name and comments regarding appointment
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Client's initials
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[SALON & SPA] New Client Intake & Health History

[SALON & SPA] New Client Intake & Health History

YOUR SKIN

DEAR CLIENT, PLEASE SCROLL DOWN TO THE BOTTOM AND SUBMIT YOUR FORM (the info below is for OFFICE USE ONLY. Do not enter any info please)

DEAR CLIENT, PLEASE SCROLL DOWN TO THE BOTTOM AND SUBMIT YOUR FORM

(the info below is for OFFICE USE ONLY. Do not enter any info please)